| NPI | 1639591555 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NY 017283) |
| Additional Taxonomies | 363AM0700X Physician Assistant Medical (Licence: NY 017283) |
| Enumeration Date | 2014-01-12 |
| Last Update Date | 2024-01-02 |